This section provides an overview of the availability of PAC services throughout the United States. We focus on the overall distribution of providers by state, the number of providers per 1000 beneficiaries/state and the differences in the share that are freestanding versus hospital-based providers.

In 2007, according to analysis of the Online Survey and Certification Reporting System (OSCAR), there were almost 26,000 post-acute providers in the United States. The majority of PAC providers are the 15,056 SNFs and the 9,286 HHAs, followed by the 1,203 IRFs, and 397 LTCHs. The majority of SNFs, HHAs and LTCHs tend to be freestanding providers whereas IRFs are primarily hospital-based units.

As Figure 3-1 and Table 3-1 show, the geographic distribution of SNFs, IRFs, and LTCHs varies widely across the United States. Overall, Texas had the most PAC providers, with over 3,000. California, Florida, Ohio, and Illinois all had between 1,245 and 1,964 PAC providers in 2007. In contrast, 26 states (particularly in the Midwest and West regions) had fewer than 350 freestanding or hospital-based SNFs, IRFs, HHAs, and LTCHs in 2007.

Figure 3-1 is titled "Distribution of Freestanding versus Hospital-Based SNFs, IRFs, and Freestanding and HWH LTCHs in 2007." It is a map the total number of SNF, IRF, and LTCH providers by state. There are five levels of shading based on total number of providers per state. The levels of shading correspond to the following breakdowns: 1.) 73-310 facilities per state; 2.) 311-754 facilities per state; 3.) 755-1,364 facilities per state; 4.) 1,365-3,079 facilities per state; and 5.) 3,080-4,568 facilities per state. States with the fewest total providers include Nevada, Idaho, Montana, Utah, Wyoming, North Dakota, South Dakota, New Mexico, Alabama, Hawaii, West Virginia, Maine, New Hampshire, and Vermont. States with the highest number of total providers include California, Texas, Florida, Illinois, Ohio, and Pennsylvania. In addition to looking at the total number of providers per state, this map also displays the location of each type of freestanding or hospital-based provider across the United States. The source for this analysis was the 2007 POS data.

SOURCE: RTI analysis of 2007 POS data.

Table 3-2 shows the number of acute, SNF, IRF, and LTCH beds per 1,000 beneficiaries. This provides more information on the supply of post-acute care relative to the Medicare beneficiary population in each state. The picture of availability changes somewhat once we control for population size. Texas, which has the highest number of PAC providers, also ranks very high in the number of beds per beneficiary. However, after controlling for Medicare beneficiaries residing in the state, Texas ties with Nevada for the state with the fourth highest number of IRF beds per 1,000 beneficiaries (1.53 beds per 1,000 beneficiaries) but ranks 16th in the number of SNF beds per 1,000 beneficiaries (45.22 beds per 1,000 beneficiaries) and 5th in the number of LTCHs bed per 1,000 beneficiaries (1.51 beds per 1,000 beneficiaries). The other high volume states, such as California are not among the top 20 in terms of beds per 1,000 beneficiaries. States with the highest supply of IRF beds per beneficiary included the District of Columbia (2.66 beds per 1,000 beneficiaries), Louisiana (2.09 beds per 1,000 beneficiaries), Arkansas (1.82 beds per 1,000 beneficiaries), and Texas and Nevada (both 1.53 beds per 1,000 beneficiaries). The states with the highest supply of SNF beds per beneficiary population included North Dakota (62.69 beds per 1,000 beneficiaries), Iowa (59.98 beds per 1,000 beneficiaries), and Louisiana (57.66 beds per 1,000 beneficiaries). The two states with the highest number of LTCH beds per beneficiary included Massachusetts (3.92 beds per 1,000 beneficiaries) and Louisiana (3.08 beds per 1,000 beneficiaries). Delaware was the state with the lowest supply of acute hospital beds per beneficiary (2.90 beds per 1,000 beneficiaries), Maryland had the fewest IRF beds per beneficiary (0.19 beds per 1,000 beneficiaries), Alaska had the fewest SNF beds per beneficiary (11.14 beds per 1,000 beneficiaries), and seven states had no LTCH beds (Montana, New Hampshire, Alaska, Iowa, Maine, Vermont, and Oregon). This analysis demonstrates the variation in supply of providers across the nation as well as the variation in supply of providers per Medicare beneficiary. This variation has implications for use of services during episodes of post-acute care.

LTCHs are among the smallest number of PAC providers. These hospitals treat medically complex cases often following discharge from an acute intensive care unit (Gage et al, 2007). They are not available in all parts of the nation, although they have grown immensely over the past 20 years, more than doubling in number. The majority are located in the Northeast and Southern parts of the United States. In 2007, there were 397 LTCHs in the United States, the majority of which were freestanding (258, or 65.0 percent) as opposed to being located with acute hospitals, so-called hospital within hospitals (HWH). It is notable that the majority of states in the West region and a large proportion of states in the Midwest region had fewer than 9 LTCHs per state in 2007. The exception was California, which had 14 LTCHs (all freestanding) and Oklahoma, which also had 14 LTCHs (11 of which were freestanding). Most notably, the states of Montana, New Hampshire, Alaska, Iowa, Maine, Vermont, and Oregon had no LTCHs in 2007. Although overall, most LTCHs were freestanding in 2007, Texas, Ohio, and Pennsylvania, were the states with the most colocated HWH LTCHs, with 26, 13, and 12, respectively. HWHs include colocated providers and satellite facilities. Texas also had the most freestanding LTCHs (46), followed by Louisiana (31). Overall, between 2006 and 2007, there was a slight shift in the number of freestanding versus HwH LTCHs. The number of HWH LTCHs decreased 6.0 percent from 148 to 139 and the number of freestanding LTCHs increased from 244 to 257.

The next set of tables examines differences in the proportion of episodes that are discharged to freestanding, subprovider, or colocated PAC services and how these patterns differed from 2005 to 2006 (Table 3-3). These numbers reflect the supply of each type of provider nationally. For example, LTCHs are primarily freestanding hospitals. In 2005, 20.4 percent of acute discharges to LTCHs nationally were to colocated LTCHs, which include LTCHs within 250 yards of the acute provider (Gage, Morley, Constantine, et al., 2008). However, this proportion did decrease to 16.3 percent in 2006. A potential explanation for this decrease may be related to CMS' new policy in FY 2005 limiting the proportion of total LTCH admissions from collocated acute hospitals. This policy, known as the 25 Percent Threshold Rule, limited the number of LTCH admissions from colocated acute hospitals to 25.0 percent of an LTCH's total admissions. Across the other types of PAC providers (IRF, SNF, and HHA), there were only very slight changes in the proportion of beneficiaries discharged to each type of provider between 2005 and 2006.

Although we observed that the total number of freestanding IRFs in the United States is relatively small, the volume of discharges to freestanding IRF providers was approaching half of all beneficiaries admitted to IRFs following discharge from the acute hospital. This is due to the fact that freestanding IRFs are generally much larger than rehabilitation units within acute hospitals. The majority of discharges to SNFs and HHAs are to freestanding providers. The proportion of discharges to providers that are colocated, but do not have a formal subprovider relationship is very small for IRFs, SNFs, and HHAs (all less than 3.0 percent).

Table 3-3. Proportion of Discharges to each First PAC Setting, by Organizational Relationship, 2005 and 2006

There were 1,203 IRFs in the United States in 2007 compared to 1,224 in 2006. The vast majority of IRFs are hospital-based (983, or 82.0 percent). Texas was the most densely populated in terms of IRFs, with 118 (84, or 71.0 percent hospital-based). After Texas, the three states with the most IRFs were Pennsylvania with 82 IRFs (64, or 78.0 percent Hospital-based), California with 79 IRFs (73, or 92.0 percent hospital-based), and New York with 70 (100.0 percent hospital-based). In contrast to these states, the majority of U.S. states had fewer than 20 IRFs. In fact, Hawaii had only one IRF in 2007. Though hospital-based units are more common than freestanding IRFs, IRF units are generally smaller and have a lower volume of admissions compared to freestanding IRF providers.

There were 15,056 SNF providers in 2007. SNFs are by far the most prevalent type of post-acute care facility in the U.S. In contrast to LTCHs and IRFs, the vast majority of SNFs were freestanding (13,929, or 93.0 percent). The three states with the most SNFs in 2007 were California, with 1,197 (1,063, or 89.0 percent, freestanding), Texas, with 1,075 (1,038, or 97.0 percent, freestanding), and Ohio, with 956 (916, or 96.0 percent, freestanding).

Home health agencies are also widely available across the United States. There were 9,286 HHAs in 2007. Of these, 17.3 percent were hospital-based and 82.7 percent were freestanding. States with the highest numbers of home health agencies include Florida (827 home health agencies) and Texas (1,738 home health agencies).

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